The SCPN newsletter: Volume 9, Issue 4 by The SCPN

SCPN

Newsletter

Scottish Cancer Prevention Network - Evidence to Practice and Policy VOL 9. ISSUE 4 VOL 8 . ISSUE 4

SCPN The SCPN are committed to getting the word about cancer prevention out to individuals, health professionals, policy

Great to have you on board Laura! Laura Patton has joined the SCF and SCPN as a research and development graduate. Laura has been placed with us as she is participating in

Are you up to speed with the SCPN blogs? We love chatting to you in our blogs about all things cancer prevention related. Recently we’ve

makers and government. We want to let everyone know what they can do to stack the odds against developing cancer through lifestyle choices. It’s not enough for individuals to attempt to change. Health professionals, cancer charities

and other agencies with an interest in this field want to be informed about the latest research on how to support that change. Policy makers and government also have a role to play in ensuring our environment and legislative structures enable change

Charityworks, the UK non-profit sector’s highly prestigious graduate programme. Over the next year Laura will be helping to raise the profile of the SCF and SCPN through our social media platforms and written communications.

covered How young adults can #BeFree and achieve more…; three on #SitLessMoveMore; and of course GoSober for October… and beyond.

rather than inhibit it. We promote action for cancer prevention by disseminating news on recent research, initiatives and events through our website, newsletters and social media platforms.

Join our network www.cancerpreventionscotland.org. uk/subscribe/

www.cancerpreventionscotland.org. uk/students/join/ Follow us on the blog website https://scpnblog. wordpress.com/ to hear about a new blogpost as soon as it hits the ground.

@thescpn

Healthy Meetings

The SCPN Art & Design Prize for Creative Communication 2018

Every year we search the degree shows of our Scottish Art Colleges for projects which relate to

#IAMANDIWILL SCPN Conference 2019 We are excited to announce our World Cancer Day 2019|SCPN conference which will take place on the 4th February 2019 in the National

behaviours which may impact on cancer risk. The work can be in any medium and previous winners have been wide and varied. This year we were delighted to come across a project by Amy Steindl entitled ‘PitStop’. Amy’s concept was to develop a service to promote worksite wellbeing by encouraging employees to walk to local independent cafes in their break times. The service asks the user how many steps they have walked that day to offer the furthest appropriate café. In addition to cafes the location of park benches is also given if users Museum of Scotland, Edinburgh. Booking will open shortly so please do visit our website to reserve your place. We are busy finalising our programme but a draft can be accessed here.

have brought their own food. Amy researched the need for this service by interviewing office workers to see what they would like and reviewing the literature on physical activity and cancer among other things. She identified that some office blocks are so well equipped with for example on site coffee shops that employees have no need to leave the building and spotted the gap which she hopes PitSpot will fill. Users can monitor their own progress in visiting all the available cafes and motivate themselves to travel further afield.

www.cancerpreventionscotland.org. uk/what-we-do/healthy-meetings/

Take our short survey ‘We’re listening

https://www.surveymonkey.co.uk/r/ SCPNfeedback2018

VOL 9, ISSUE 4

Editorial

Inside this issue

In this issue we focus on the Scottish Government’s new delivery plan on ‘A healthier future – Scotland’s diet and healthy weight delivery plan. Comments abound and they reflect the complexity of both the prevention and management of obesity – clearly there is no one single route to achieve change. We are disappointed that this policy gives minimal recognition to people with obesity who are at higher risk of cancer and indeed cancer survivors who fare less well with excess body weight. There is a very great need to move out of the “fat shaming” debate to offering acceptable and supportive help for those ready to take steps to reduce body fatness. In this issue we report on three cancer charities in Scotland doing just this… working in partnership to support behaviour change. It is very disappointing to see cancer written out of this policy given the excellent examples of effective weight management already demonstrated by randomised controlled trials in cancer settings.

04. Turning Words into Action

For many years we have been highlighting the actions taken to reduce tobacco use and how this approach might be applied in a food context. The classic approach in social marketing is to think about a combination of the product (e.g. food composition, portion size), the price (e.g. sugary drink taxation), placements (e.g. availability of junk products) and promotions (e.g. money off deals, upselling). The UK and Scottish Governments have clearly declared action on promotions, taken one regulatory action on price (taxation on sugary drinks) and started conversations (and guidance) about product composition (sugar content). So we will see a bit of action but we will mostly ignore the visibility, availability, and placement of energy dense foods, price action beyond sugary drinks (which have been decreasing in intake for the last decade) and regulation on composition and portion size. The proposed actions will take work and commitment but the lessons learned from tobacco control seem to have been set to one side. This is not about banning energy dense foods (we have never banned tobacco after all!) but a comprehensive plan is needed to make it less easy and less desirable to have the very wide range of energy dense, non-essential foods and drinks available at every opportunity. There is a threat of “appropriate action” if current sugar and calorie reduction targets are not met, but nothing firmer. We are sceptical of the impact of the current plan on the impact of obesity especially in adults, and we think the failure to set an obesity reduction target in adults also indicates a lack of confidence in achieving significant change anytime soon.

Professor Annie S. Anderson @anniescotta Professor Bob Steele @BobSteele6 VOL 2 . ISSUE 4

Chips To Go 05. Scottish cancer charities get into action on obesity. 06. A healthier future: Scotland’s diet and healthy weight delivery plan 08. WCRF partners in EU project to prevent childhood obesity Kyriaki Christou – SCPN students 09. Kale, Lentil and Lemon Soup 10. Please forgive us for mentioning Christmas in October…. Cross-border reflections on Stoptober and e-cigarettes 11. Walking netball… 12. Scotland, we are survivors! Irelands passes landmark alcohol legislation A few minutes to check your breasts 13. Have you seen this paper? Cervical cancer screening – ensuring messages and services are relevant to everyone 14. Cancer Incidence in Scotland 2016 15. Expert insight 16. Cancer and lifestyle – research round up

The Team Dr Maureen Macleod - SCPN Fellow Jill Hampton - Network Administrator Bryan Christie - Journalist Eoin McCann - Designer Connor Finlayson - Digital Communications

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Turning Words into Action Lorraine Tulloch, Programme Lead, Obesity Action Scotland Will 2018 be the year that words on improving diet and tackling obesity finally turn into actions? The need to move beyond education and behaviour change to tackling Scotland’s unhealthy food environment has become urgent and this year saw two new and important publications. The UK Childhood Obesity Plan Chapter 2 and the Scottish Government’s Diet and Healthy Weight Delivery Plan. Within

these documents we see significant commitments, including tackling in-store promotions, TV and online advertising and energy drinks. Such actions will form an important starting point in changing the food environment that influences our everyday choices. The documents promise consultations on many issues and we have already seen the first of these consultations being issued: energy drinks, calorie labelling

in England and in-store promotions in Scotland. The proposals need to be bold and ambitious and need to give clear timescales for implementation. Please respond to these consultations with your support for action. Improving the food environment is an important step in cancer prevention.

Chips To Go Anna Gryka, Obesity Action Scotland The book I referred to most often as a nutrition student was the Food Portion Sizes booklet by the Food Standards Agency, an irreplaceable source of information when analysing a food diary. This booklet has the answers. All I had to do was to enter weights of food and drink into the nutrition analysis software and voila! I knew everything about the diet of a patient: calories, macronutrient composition, vitamins, minerals, fibre, and more. Eating out of the home has become a regular part of our modern lives, with up to a quarter of calories eaten out of the home in the UK. Food Standards Scotland reported that chips are the food item most commonly purchased out of the

home in Scotland. We were interested what impact chip consumption might have on obesity. So we went to thirty takeaway shops in Glasgow, bought all available portion sizes of chips and weighed them (the ‘Chips To Go’ study http://www. obesityactionscotland.org/changing-thegame). The findings were shocking. Firstly, there was a wide variation in available portion sizes: from 120g to 755g. Secondly, we estimated calorie content of an average portion of chips (380g) and found that it contained around half of a woman’s daily recommended calorie intake. Finally, we compared today’s average portion to the typical serving of chips from the

FSA booklet. Our average portion of chips was 80% bigger than the FSA booklet portion size. Why? The year of publication gives a hint. The latest edition of the booklet is from 2002 i.e. from 2002-2018 “normal” portion of chips shifted from 210g to 380g. There is a worldwide obesity crisis. In Scotland, 65% of people carry excess weight. It is not only up to the health service to fix it. We all need to fix it. There is an important role for the out of home sector too and it is urgent. Menus should be labelled with calories so people know what they’re eating, there should always be a choice of smaller portions, and healthier foods should be promoted.

The views and opinions expressed in this newsletter are those of the individual contributors and are not necessarily the views or opinions of the Scottish Cancer Prevention Network/Scottish Cancer Foundation or any of its officers

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Scottish cancer charities get into action on obesity. Note from the Editor: Too bad the obesity plan isn’t investing more money in obesity management for people at risk of obesity related cancers – but it is great to see the third sector putting action into place.

ActWELL study A big hurrah for breast screening clinics in Dundee, Aberdeen, Edinburgh and Glasgow who have helped us recruit 560 women to the ActWELL trial. Recruitment is now closed and 97% of women allocated to the intervention group have

BeWEL - From Research to Practice In our last issue (https:// thescpn.org/2DYHxkF) we reported that the Scottish Government are supporting a feasibility study to roll

Maggies’ Weight Management Group for Endometrial Cancer

Lesley Howells, Centre Head, Maggie’s Dundee Maggie’s Dundee have been working with the Gynaecological Surgery team at Ninewells Hospital to develop and run a weight management programme for overweight and obese women with endometrial cancer. It is estimated that over 70% of women with endometrial cancer are overweight or obese (1) which is associated with morbidity during and

seen a Breast Cancer Now Coach for their face to face intervention session. Retention at the 12 weeks follow up call is currently 96%. Last month the first people to complete the study were seen and now people are rolling in to see the research nurses for their final 12 month follow up

visits. All participants will have finished the study by August 2019 and differences in body

out the evidence based, effective BeWEL programme – a lifestyle and weight management intervention for people at increased risk of bowel cancer due to an adenoma detected through the national bowel screening programme. Bowel Cancer UK have now started training up the first batch of volunteers to take this work forward – once again a great response from volunteers with a commitment to reducing

cancer risk in Scotland. Endoscopy staff, in Tayside and Paisley are also on board and a very enthusiastic team of NHS champions await clients from mid-October. It has been wonderful to hear the nursing staff embrace this opportunity to help guide folks with lifestyle changes …. The only disappointment has been that more patients with weight problems (but who haven’t had adenomas) can’t be offered the programme. For

following surgery, a two‐fold increased risk of endometrial cancer mortality, and reduced quality of life (2, 3).

the design of the programme from psychologists (providing cognitive behavioural therapy, self‐monitoring, motivation, attitudes and beliefs, action planning, problem solving, and relapse prevention strategies); a cancer nurse; dietitian (psychoeducation about nutrition and eating healthily, with practical demonstrations of cooking healthy recipes); and an exercise specialist (seated exercises including aerobic exercise and strength training).

The design of the programme followed the Scottish Intercollegiate Guidelines Network evidence‐based recommendations on the management of obesity which state that overweight and obese individuals should be supported to lose weight with a multicomponent weight management programme incorporating dietary change, physical activity and behavioural therapy. Maggie’s included input in

weight and physical activity will be closely scrutinised by the research teams.

more details about the project contact Ross Lamb ross.lamb@ bowelcanceruk.org.uk.

is well attended with no drop‐outs. Feedback has been very positive, rating the group support and style of facilitation highest. All in the first group lost some weight (1.8kg to 7.9kg), had reduced depression and emotional/ uncontrolled eating, and increased cognitive restraint by the end of the programme.

The programme (15 weeks, 2 weekly one hour sessions)

1. von Gruenigen VE et al. (2006) Treatment effects, disease recurrence, and survival in obese women with early endometrial carcinoma : a Gynecologic Oncology Group study. Cancer. 2006 Dec 15;107(12):2786-91. 2. Papatla K et al. (2016) The obese endometrial cancer patient: how do we effectively improve morbidity and mortality in this patient population? Annals of Oncology, 27, pp.1988‐1994. 3. Shaw, E., Farris, M., McNeil, J., Friedenreich, C., 2016. Obesity and Endometrial Cancer. Recent Results in Cancer Research, 208, pp.107‐136. The views and opinions expressed in this newsletter are those of the individual contributors and are not necessarily the views or opinions of the Scottish Cancer Prevention Network/Scottish Cancer Foundation or any of its officers

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A healthier future: Scotland’s diet and healthy weight delivery plan Note from the Editor: Following consultation which resulted in 362 responses, the Scottish Government’s

‘A healthier future: Scotland’s diet and healthy weight delivery plan’ was published in July 2018. We asked

several experts working in the field of cancer to provide their comments on the new plan.

Professor Mike Lean, University of Glasgow

when it comes to supporting effective treatments for obesity. It confirms that the successful multidisciplinary Scottish Football Fans in Training project will continue to be supported, and a total of £42m over 5 years will include intensive weight management for people whose weight gain has led to type 2 diabetes. This follows the publication of the Glasgow and Newcastle-based DiRECT trial, in which the Counterweight-Plus programme has led almost half of all its participants into a remission of type 2 diabetes, no longer diabetic and off all medication at I year. The key to success in both these projects has been in using well-researched evidence-based Scottishdesigned interventions, and in collecting, analysing and publishing the complete

results from every person who attempted the treatment. Successful strategies are those based on solid evidence.

for Scotland. In it they recognised “widespread and incessant promotion and advertising of foods which should form only a very small part of the overall diet”.

influencing what we eat and ultimately influencing our weight as a nation.

This eagerly-awaited report registers government recognition that action is required against obesity, and contains several valuable new actions. However as is so frequent in such documents, they are buried in a sea of other listed initiatives, compiled because they might theoretically influence food choice or physical activity, and thus potentially impact on obesity. All are well-intended, and might tend to benefit general health. Governments like to tell voters that they are initiating or supporting large numbers of activities, but these will have little ultimate effect on obesity. The strategy document is more incisive

Lorraine Tulloch, Programme Lead, Obesity Action Scotland Radical or deliverable? What is most important at this stage? When you read the Diet and Healthy Weight Delivery Plan you could be saying I have heard all this before, nothing new here. You wouldn’t be wrong. In July 1996 the Scotland Office launched Eating for Health: a Diet Action Plan

Sally Greenbrook, Policy Manager, Breast Cancer Now The publication of Scotland’s obesity strategy provided a vital opportunity to tackle the obesity crisis in Scotland head-on. Breast Cancer Now welcomes the commitment in the strategy to addressing the obesogenic environment, particularly the emphasis on encouraging people to make healthier choices when buying food. The strategy committed to consulting in the autumn on measures

20 plus years on and we are still having the conversation about the impact of promotion and advertising. In the meantime, billions of pounds have been spent by the industry

to restrict the promotion and marketing of unhealthy food – we look forward to participating in this consultation and urge the Scottish Government to follow this consultation with swift legislative action. We are disappointed that the obesity strategy action plan does not include a commitment to programmes such as ActWELL which aims to make use of ‘health defining’ moments to identify and support people to make positive lifestyle changes. The ActWELL trial identifies

All strategies need to be kept under review. The announcement of a monitoring and evaluation framework is reassuring. One suspects the wild pledge to reduce ‘childhood obesity’ by 50% by 2030 may need to be revised downwards (and it is by no means certain that this would greatly reduce later adult obesity, without similar effort across the lifespan). There is still no specific target for adult obesity, when the vast majority of complications, disabilities and costs arise. Having no target makes it difficult to evaluate a strategy or its implementation.

So, however much we yearn for radical action, the outstanding issue is the implementation of change. Delivery of change in the food environment can only be brought about by regulation. The radical nature of this year’s plan may be that it is the first to deliver change. Let’s hope so.

women through the breast screening programme and seeks to reduce their risk of developing breast cancer through one-to-one coaching to help them to make sustainable lifestyle changes, focusing on physical activity, diet and body weight. ActWELL was highlighted in the consultation document prior to the publication of the strategy and we are disappointed that the importance of ‘health defining’ moments is not included in the action plan.

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Dr Andrew Fraser, Director of Public Health Science, NHS Health Scotland What the current diet and obesity plans illustrate starkly is that Governments cannot turn round the epidemic of obesity by themselves. Above all, food

Gregor McNie, Head of External Affairs, Cancer Research UK It’s simply not enough and will never make any difference. Or, it’s a heavyhanded state overreach. Commentaries deriving from both sentiments inevitably follow any actions that Scottish Government would propose to tackle the nation’s obesity crisis. Political reality dictates that achieving some balance between the two is their task, and we very much support their level of ambition. For those who don’t smoke, overweight and obesity are the biggest preventable risk factors for cancer and, unfortunately, prevalence is now across the majority of our population. All in relatively recent times too. Some analysts will talk about historically diminishing physical activity levels leading to this, or increasing them being the biggest solution available. But the evidence just won’t back this up. Physical activity levels are, in fact, higher than ever, and even the calories burned in a daily 5k run can be outdone by a chocolate bar. (Of course, physical activity has excellent cancer prevention benefits, and for wider physical and mental health, but the topic in hand is Scotland’s obesity crisis).

and drink retailers have to play their part. We know that marketing works, that their prime reason is to increase sales and profit and not health, and at present it encourages us to eat more of the things we need to eat less of. Unless retailers change their business

model which pushes for greater and greater consumption without regard for the public health consequences, Scotland will not be able to tackle our dangerous and destructive obesity epidemic effectively.

unadulterated thus far and inextricably connected to our nations’ overweight status.

to be welcomed and supported.

That doesn’t make us all unconscious consumers, utterly at the whim of commercial forces- but there are few who avoid their impacts. The body of science, research and translation into our supermarket environments is vast and formidable- undoubtedly encouraging us all in our purchasing. Not all these factors are negative in of themselves but they are when the majority of the promotions, marketing and nudging is towards the foods of least nutritional value. Each day we’re taking in an additional 110 tonnes of sugar via promotions alone! The various proposals to begin regulating this have

At Cancer Research UK we have focussed particularly on junk food multibuy offers- with evidence showing they can drive additional unplanned purchases and increase consumption. Interestingly, public polling also shows support for their restriction- perhaps recognising the help it would give in tipping the balance of offers to making the healthy choice the easier one. We’d especially want to see these offers regulated as voluntary efforts to date have simply not impacted sufficiently. A better future is in sight, with a range of helpful shifts to our food environment that we should all support. Let's help bring across the line this commendable plan.

We were all leaner not that long ago and the historical shifts to observe around that are those in our food environments. Decreasing numbers of independent greengrocers and whole food shops. Increasing processed offerings. Normalisation of snacking. Trends of added sugars. Rise of fast food. Hugely effective research-based marketing and promotion techniques. Swathes of new advertising channels. All fairly

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WCRF partners in EU project to prevent childhood obesity Deborah Hyde, World Cancer Research Fund disseminate policies to tackle obesity among their peers.

World Cancer Research Fund (WCRF) International has secured EU funding - as part of a consortium of 14 international research and advocacy organisations - for a five-year project working with young people across Europe to create, inform and

With 31% of 5- 17 year olds in the UK expected to be overweight or obese by 2025 and with obesity and overweight recently linked to 12 different cancers in WCRF International’s global cancer prevention report (www.wcrf. org/dietandcancer), the new project is very timely. Entitled Confronting Obesity: Co-creating policy with youth (or CO-CREATE), young people will be centrally

involved, designing policies and advocating practices they believe will help improve adolescent health. WCRF International’s role will be to build on its unique NOURISHING framework and policy database, which outlines a comprehensive approach for governments to promote healthy diets, to develop a complimentary policy framework and database for physical activity. “We look forward to supporting governments

to develop and implement effective policies that create healthy environments for children and young people in Europe,” said Dr Kate Allen, Executive Director of Science and Public Affairs with WCRF International. You can follow the progress of CO-CREATE online: www. co-create.eu or on Twitter: @ eu_cocreate and @wcrfint. Find out more about WCRF International’s NOURISHING database at: www.wcrf.org/ NOURISHING

SCPN’s European Cancer League Youth Ambassadors Kyriaki Christou, 4th year medical student, University of Dundee In August I attended the European Cancer Leagues Youth Ambassadors (YA) summer school which took place at the French Cancer League in Paris https://www.ligue-cancer.net/ along with 30 other young people from across 27 EU countries, from different backgrounds but one common goal: to prevent cancer. Most YA were medical students however, more interestingly, some had a background in a nonmedical field e.g. economics, and international relations, many of whom had a personal/family experience of cancer The aim of the summer school was to equip us to be able to make changes to reduce cancer risk in the countries we were representing. Talks included the principles of persuasion, how to address vaccine hesitancy, as well as the use of IT for patient empowerment. Some YA presented the actions they had taken in their countries, such as organising fayres against cancer prevention or talking on popular TV shows. Learning about their struggles and persistence was truly inspiring, showing their dedication.

I am honoured to represent both Cyprus, my home country, and Scotland, where I have lived for the past 4 years. The dual ambassadorship leaves me with mixed feelings however. Cyprus lacks action on cancer prevention (e.g. fully implementing the no-smoking law passed many years ago). Also I am very proud to

be part of the Scottish Cancer Prevention Network, which was referred to on many occasions as a good example of positive change. We also prepared for the joint action across all countries, in collaboration with the UICC, for the 2019-2021 World Cancer Day campaign (I am and I will).

Left - Dr Elizabeth McLennan, Right - Kyriaki Christou

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Kale, Lentil and Lemon Soup Kellie Anderson, MSc kelliesfoodtoglow.com

This healthy, colour-packed soup recipe scoops up some key antiinflammatory ingredients and simmers them up in a silky autumnal broth. • 2 tbsp extra virgin olive oil • 1 red onion peeled, finely chopped • 2 celery sticks finely diced • 2 medium carrots finely diced • 3 garlic cloves peeled, finely minced/grated • 1.5 tsp ground turmeric or fresh, grated • .25 tsp black pepper freshly ground • .25 tsp ground allspice optional • .5 tsp chilli flakes • 2 tsp rosemary leaves finely minced • 150 grams red/orange lentils rinsed • 1.7 litres light vegetable stock. I use Marigold Swiss Vegetable Bouillon

• 8 sun-dried tomatoes, sliced • 80 grams kale sliced or chopped into bite-sized pieces (or chard) • .5 unwaxed lemon juice and zest, more to taste • 1 handful parsley chopped • extra olive oil for serving Method 1. Heat the olive oil in a mediumlarge saucepan over low-medium flame. Add the onion and celery. Cook, stirring occasionally, for 5 minutes or until softened. Add the garlic, celery, carrots, turmeric, pepper, allspice, rosemary and chilli flakes. Cook, stirring, for 2 minutes or until smelling gorgeous and garlicky. 2. Add in the lentils and stock. Bring to the boil. Reduce the heat to low and partially cover. Simmer for 20 minutes, until lentils are tender.

3. Stir in the kale, sun-dried tomatoes and lemon zest to the soup. Bring back up to simmer for 5 minutes. Stir in the lemon juice and parsley and serve warm, rather than hot. This brothy soup tastes best on the day, but freezes and reheats well. If you know you won’t be eating it for a day or two, leave out the last-minute additions of kale, sun-dried tomatoes and lemon juice until you reheat the broth. To make the broth heartier, add a handful of cooked grains. Adding uncooked into the broth will “muddy” it, but that’s just a cosmetic thing. Add more stock if using uncooked grains.

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Please forgive us for mentioning Christmas in October…. and many struggle with Christmas – parties, drinks, gifts and social events that bring more calories than most people cope with. Some people love the indulgence, some people dread it … here are some starting ideas for those busy health care colleagues, work mates and secret Santa gifts to dilute the boxes of biscuits and chocolates but still have something to share?

Did you read our blog last year with the great title ‘Christmas is coming and the goose is getting fatter… Aren’t we all?’ https://scpnblog.wordpress.

com/2017/12/04/christmas-is-comingand-the-goose-is-getting-fatter-arent-we-all/ Two thirds of Scottish adults are overweight

1. Relax/care hamper – selections of mini bath oils, bath bombs, bubble baths, rubber ducks, tea lights. 2. Balmy selection – lip balms for all. 3. Dream away luxury – a subscription to a travel magazine for the staff room. 4. Book of inspirational quotes - for that long working day. 5. A super-duper basket of fresh fruits. Check out more on https://scpnblog. wordpress.com/

Cross-border reflections on Stoptober and e-cigarettes Sheila Duffy, Chief Executive ASH Scotland As the year turns to autumn, October has increasingly become a focus for encouraging people to follow through on their resolutions to quit smoking and/or drinking alcohol. Public Health England’s (PHE) annual Stoptober campaign provides a welcome boost in terms of public awareness. Mass media encouragement to quit smoking is definitely a welcome feature in the autumn landscape, and Stoptober messages cross the border into Scotland, raising expectations here. This year’s Stoptober features prominent encouragement to try e-cigarettes, with PHE entering into partnership with the Independent British Vape Trade Association (IBVTA) to direct would-be quitters to local retailers and possible discounts on purchases. I do have some concerns about PHE’s driving focus on e-cigarettes. They have a place, but no one quit method works for everyone. Evidence so far suggests that e-cigarettes

are less harmful than tobacco, but to gain any benefit you have to quit smoking completely. There is still a lot we do not know about e-cigarettes, and the term covers a fast changing range of products and different ways of using them. While commercial nicotine providers are keen to position themselves as stakeholders in public health policy debates, their arguments focus on commercial solutions. In Scotland, the ‘Quit your Way’ approach has the potential to spark a wider, more open conversation that explores what routes an individual smoker might choose to quit tobacco, and to stay quit. Public health interests take in wider population level effects, and must take account of the Scottish and international evidence independently associating youth e-cigarette use with smoking.

billboards and sponsorship. I trust we will frame this debate with the aims of both reducing tobacco use, and building a generation free from tobacco. The spectrum of harm reduction should not end at commercial nicotine delivery options, and any changes to e-cigarette regulation must be aimed both at helping smokers to quit and at preventing young people from starting on either e-cigarettes or tobacco.

In the foreseeable future Scotland will debate regulations to limit domestic advertising of e-cigarettes, such as

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Walking netball....

Dr Elaine Bannerman, Lifelong netball enthusiast

Fancy getting involved in something fun, sociable which also has health benefits…? What’s not to like! Sport can be intimidating for women… we can find it daunting, we shy away from it – but we shouldn’t, we need to find ways in which we can get involved and enjoy it – have fun. The World Cancer Research Fund concluded that there is strong evidence that physical activity protects against cancers of the colon, breast and endometrium, and that it helps prevent excess weight gain. Netball is one of the fastest growing participation sports in Scotland; one of the legacies of the Glasgow 2014 games. You may recall the traditional game at school, standing outside in the freezing cold, waiting for the ball to come down to your end of the pitch, that you wished you were taller…

However in recent years alternative versions of the game have been developed to make this sport more accessible to women of all ages and abilities. Bounce-back to netball and walking netball are where the sport is really growing and women across Scotland are getting involved, having lots of fun and seeing the benefits. In the summer of 2017, Netball Scotland joined forces with Age Scotland to Launch Walking netball Across Scotland. Walking netball is suitable for all ages, abilities and fitness levels. It is just like netball but it is played at a slower (walking) pace on a smaller court - but with just as much fun. And if you’ve never played before it doesn’t matter - you will quickly learn all the basics. Bounce back to netball is suitable for women over the age of 18 years, for

those who haven’t played before or those that haven’t played for many years. After perfecting the basics, fun games are often set-up between different bounce-back teams – again it is all about having fun whilst being active. More information can be found on ‘Netball Scotland’ website [https:// www.netballscotland.com/getinvolved/walking-netball/] and also ‘Netball Scotland Walking Netball’ Facebook page [https://www. facebook.com/nswalkingnetball/ Netball Scotland]. This gives details of a number of walking netball sessions that are happening all over Scotland. For more information on how to set up a Walking Netball session contact Kate Thomson (Community Impact Officer) M: 07825 638980, E: walkingnetball@netballscotland.com

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Scotland, we are survivors! A new 6 week Detect Cancer Early campaign, ‘Survivors’, launched across TV, radio and social media last month. It aims to reduce the fear that still exists around cancer and empower people to ‘act early’. The campaign

directs people to visit getcheckedearly.org for more information on signs and symptoms to look out for (including a new interactive checker) and read survivor stories which are also available on Facebook https://www.facebook.

com/theweec/. There are useful resources at http://www. getcheckedearly.org/ resources and if you missed the TV advert it’s here https://www.youtube.com/ watch?v=npsidDMPqnk.

Ireland passes landmark alcohol legislation carcinoma) and Stomach) the World Cancer Research Fund recommend that for cancer prevention it’s best not to drink, but if you do decide to drink to keep below the government’s recommended level of 14 units per week.

Due to strong scientific evidence that all types of alcoholic drinks are a cause of

several types of cancer (Breast, Bowel, Liver, Mouth and throat, Oesophagus (squamous cell

On October 3rd 2018, the Republic of Ireland passed a bill aimed at addressing the country’s drinking habits. Like Scotland, the Republic of Ireland has a somewhat unhealthy relationship with

the normalisation of alcohol consumption in society. The raft of measures being introduced in Ireland include minimum unit pricing, restrictions on advertising, health warnings on labels, and the regulation of advertising and sponsorship of alcohol products. For the first time ever the country will see the specific warning that alcohol is linked to cancer long overdue! Read more here https:// thescpn.org/2zT43Hx.

A few minutes to check your breasts Has anyone seen the Touch Look Check campaign from Breast Cancer Now which is running throughout October to mark Breast Cancer Awareness month? The great graphics show how easy it

is to check your breasts – we brought you #kettlecise and now here’s something that doesn’t take any longer than making your toast in the morning!

But the key is to do it regularly and know the signs and symptoms of breast cancer, so you know what changes to look out for. A couple of minutes once a month may just save your life – that must

be worth doing. Visit the Breast Cancer Now website to find out more. You can also follow BCN on Facebook or Instagram to see the campaign in action.

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science section 13

Have you seen this paper? GBD 2016 Alcohol Collaborators (2018) Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.

Lancet; 392: 1015–35 http://dx.doi.org/10.1016/S01406736(18)31310-2 This wide reaching study, which was based on pre-existing work, aimed to address known biases in that work. Among other study outcomes, the authors carried out a new meta-analysis to assess the dose response risk of alcohol for 23 diseases, including cancer. The level of alcohol consumption at which an individual’s total attributable risk of ill

health increased was also estimated. In 2016, one third of the world’s population were drinkers (have drunk some alcohol in the last year) and, although there was a wide variation by location, prevalence was found to be higher in more affluent areas and in males more than females. The amount that was drunk daily was also higher in more affluent areas. In 2016, 2.8 million deaths were attributed to alcohol use globally. Disease burden attributable to alcohol was found to be lower in women than men and in areas of higher deprivation compared to areas of less deprivation. Some protective effects for ischaemic heart disease and diabetes were found for both men and women especially in

more affluent areas but, for the over 50s, cancer accounted for 27% of women’s and 19% of men’s alcohol attributable deaths. In more affluent areas cancer was the main attributable burden of disease for both sexes. The level of alcohol to minimise the overall risk of ill health was 0 (95% CI 0.0 – 0.8) standard drinks daily with a steadily increasing relative risk of ill health with increasing consumption. The protective effects of alcohol in heart disease and diabetes were offset by the increasing risk of cancer with increasing consumption and would only be significant in populations where diabetes and ischaemic heart disease comprised more than 60% of total deaths in a population.

Cervical cancer screening – ensuring messages and services are relevant to everyone Dr Christine Campbell, University of Edinburgh, Christine.Campbell@ed.ac.uk Thankfully, the number of women diagnosed with, and dying from, cervical cancer has fallen dramatically since organised cervical screening was made available in the 1960s, in line with many other high-income countries. More recently, the introduction of the HPV vaccine for secondary school girls aged 11 to 13 years old brings another vital element of cervical cancer prevention for the future. However, most women in Scotland aged older than 26 years have not received the HPV vaccine and for the next three decades will be invited to screening until the upper age limit for screening (currently 64 years). Given that six women are still diagnosed with cervical cancer every week in Scotland it is really important that screening services are optimised to remove as many barriers to screening as possible. It has already been shown that breast and bowel screening participation in Scotland varies by ethnic group: the Chief Scientist’s Office in Scotland has recently funded a research project to

look at what extent this is the case for cervical cancer screening, and develop interventions to support the NHS in offering screening in culturally sensitive and appropriate ways. Over the next two years, researchers at the University of Edinburgh, working with academic and NHS colleagues across Scotland, will carry out four linked studies. First, we will describe patterns of attendance to cervical screening among different ethnic group using anonymised linkage of cervical screening and selfreported ethnicity in the 2011 Census. In parallel, we will interview white Scottish women and those from ethnic minority populations (South Asians, Eastern Europeans, Chinese, and Black African / Caribbean) to better understand attitudes to, and concerns about, screening as well as ask their views about how best to address these issues. We’ll also summarise the evidence in the scientific literature. Finally, bringing the findings of these strands together we’ll then work with

the NHS, ethnic community groups, the Scottish Government and relevant charities such as Jo’s Cervical Cancer Trust, to design new and more inclusive ways of offering screening to women, relevant to specific communities where they are needed most. Postscript from the Editor: One of the more optimistic papers in the Lancet Public Health https://www. thelancet.com/journals/lanpub/article/ PIIS2468-2667(18)30183-X/fulltext is an article on the results of a validated dynamic model of human papillomavirus (HPV) vaccination, natural history, and cervical screening which estimates an end to cervical cancer in Australia. It is estimated that cervical cancer could be eliminated (threshold four new cases per 100 000 women) by 2028 (range 2021–35 based on the specific modelling data used). The authors also predict that the mortality associated with cervical cancer could decrease below one death per 100000 women by 2034.

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Cancer Incidence in Scotland 2016 Andrew Deas, Information Services Division, NHS National Services Scotland In 2016, 31,331 people were diagnosed with cancer in Scotland (16,084 women and 15,247 men). This was an increase from 28,048 people ten years previously. As discussed in the previous newsletter (volume 9, issue 3), these figures do not include nonmelanoma skin cancer. There were 11,677 cases of non-melanoma skin cancer recorded by the Scottish Cancer Registry in 2016. Non-melanoma skin cancer is the most commonly diagnosed cancer in Scotland and the rest of the UK. However, in order to be able to compare cancer statistics with other countries, non-melanoma skin cancer is excluded from statistics for â&#x20AC;&#x153;all cancers combinedâ&#x20AC;?. The overall risk of cancer is higher in men than women. However, age-adjusted incidence rates of cancer have increased by 1.9% for women and decreased by 6.2% for men. This has reduced the gap in cancer risk between men and women over time. The age-adjusted incidence rates allow a fairer comparison to be made over time, but it is also informative to look at the number of people. The number of women diagnosed with cancer is higher than the number of men and both have increased over time. Over this timespan in women breast cancer incidence has increased by 2.9% and lung cancer by 2.4%. An increase in the number of older people in the population is one of the main explanations for the increasing number of people being diagnosed with cancer. Figure 1 shows the most common twenty cancers in Scotland in 2016 by sex (excluding non-melanoma skin cancer). Lung cancer remains the most common cancer overall with 5,045 cases diagnosed in 2016. Breast and colorectal cancers are the next most common overall with 4,636 and 3,700 cases respectively. For women, the most common are breast, lung and colorectal cancers, accounting for 55.5% of cancers in women. For men, the most common are prostate, lung and colorectal cancers, accounting for 49.9% of cancers in men. There have been significant changes in the rates of cancer over the past decade. Figure 2 shows the change in age-adjusted rates for the most common twenty cancers

by sex. For women, there has been little significant change in the rates of breast and lung cancers, while there has been a significant fall of 9% in the rate of colorectal cancers. Rates of thyroid, liver, kidney, uterine, cervical, head and neck, and pancreatic cancers have increased in women. For men, there has been little significant change in the rate of prostate cancers but falls of 18% in both lung and colorectal cancers over the past decade. Rates of thyroid, liver, kidney, malignant melanoma and pancreatic cancers have increased in men.

Further Information All statistics are based on data from the Scottish Cancer Registry presented in the Cancer Incidence in Scotland (2016) publication. https://www.isdscotland.org/ Health-Topics/Cancer/Publications/201804-24/2018-04-24-Cancer-IncidenceReport.pdf Acknowledgement Our publication uses data shared by patients and collected by the NHS as part of their care and support.

From top to bottom: Figure 1. Most common 20 cancers in Scotland in 2016 by sex (ordered by total for all persons) Figure 2. Ten year percentage change in incidence rate for the twenty most common cancers in Scotland

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Expert insight Miss Susan Moug, Consultant Surgeon, RAH | Honorary Clinical Associate Professor, University of Glasgow

kind of cancer treatment. 2. What evidence is there that patients are able to undertake prehab activities just after a cancer diagnosis? Lots and lots and lots. In addition to being safe and feasible, there is some discussion that you are empowering the patient to make their own decisions about their care at a time when they feel, not only vulnerable, but out of control (3). Patients should certainly be given the option for prehab.

Note from the Editor: Miss Moug is presenting at the 2019 SCPN conference on this topic. If you want to hear more sign up here 1. What is the difference between prehabilitation and rehabilitation in cancer care? Basically it is a timing definition. Both prehab and rehab contain the same key components (nutrition, physical activity, psychological aspects) but one is started before the first treatment for cancer (prehab) and one after (rehab). First treatment includes any type

of treatment as research has shown that prehab can be started prior to chemotherapy, radiotherapy and surgery allowing all patients with cancer to be considered for prehab (1). Rehab can start at any point after any cancer treatment. There is a small amount of evidence (2) that prehab may be better than rehab as you are anticipating the change or deterioration that a patient may undergo with their treatment and trying to offset that. A similar comparison is to running a marathon - you need to train to do it and get the best from it, exactly the same thought process as for any

3. Isn’t is unkind to add more demands to what a patient must do when they are already coping with a diagnosis? Doesn’t this make them feel guilty? You would not withhold treatment from a patient because you thought it was too much for them. You would discuss the options with them and explain the pros and cons. It is the same with prehab. If the patient is aware of the evidence that a prehab programme followed by rehab may improve their health in the short and long-term, then you are responsible as a health professional to discuss that with them. If the patient chooses not to go ahead

with prehab then that is their choice. But we should ask them again about rehab as we go through their treatment pathway. I see it as similar to smoking advice. 4. Is there any evidence that prehab makes a difference to surgical outcomes in colorectal cancer? es. A trial was published Y earlier this year from Spain (4) where patients undergoing major abdominal surgery (including for colorectal cancer) who had prehab had 50% less complications after their surgery than those that didn’t. These patients were older (70+) and had comorbidities which again, supports the evidence that prehab can benefit previously overlooked patient groups. 5. Is there a good website that provides guidance on prehab? You can look up the ACSM guidelines. However, Macmillan in conjunction with Royal College of Anaesthetists have just got together to develop guidelines for prehab that should be completed by July 2019. This group brings many different experts together and you can follow them on twitter #prehab4cancer.

1. Bott RK et al. (2017) Exercise Prehabilitation during Neoadjuvant Cancer Treatment in Patients with Gastrointestinal and Thoracic Cancer: A Systematic Review. Gastrointest Cancer Res Ther; 2(1):id1014 2. Gillis C et al. (2014). Prehabilitation versus rehabilitation: A randomized control trial in patients undergoing colorectal resection for cancer. Anesthesiology; 121:937-47 3. Silv er JK, et al. (2013) Cancer Prehabilitation. An Opportunity to Decrease Treatment-Related Morbidity , Increase Cancer Treatment Options, and Improve Physical and Psychological Health Outcomes. Am J Phys Med Rehabil; 92(8):715-727 4. Barberan-Garcia et al. (2018) Personalised prehabilitation in high-risk patients undergoing elective major abdominal surgery: a randomised controlled trial. Annals of Surgery Jan;267(1):50-56. doi: 10.1097/ SLA.0000000000002293

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Cancer and lifestyle â&#x20AC;&#x201C; research round up Park SY et al. Alcohol Intake and Colorectal Cancer Risk in the Multiethnic Cohort Study.

Am J Epidemiol. (2018) Sep 15 DOI: 10.1093/aje/kwy208 https://thescpn.org/2CrDtb7 The WCRF reported convincing

Wiseman M. Nutrition and cancer: prevention and survival.

British Journal of Nutrition Epub ahead of print DOI: 10.1017/S0007114518002222 https://thescpn.org/2PsjQ5L More and more the evidence points to cancer as a disease process which may begin many years

Song M. et al. Cancer prevention: Molecular and epidemiologic consensus

Science 361 (6409), 1317-1318 DOI: 10.1126/science.aau3830 https://thescpn.org/2EhUgPM The authors of this paper argue that decreases in cancer mortality have lagged behind those of cardiovascular disease, another preventable disease despite there being a body of strong evidence that exposure

evidence that alcohol is a risk factor for colorectal cancer (CRC) above 30g per day. Due to homogeneity in previously studied populations limited evidence existed for different ethnic groups. This study investigated the association between alcohol and risk by ethnicity, gender and lifestyle factors (n=215, 000). An increased risk of CRC was identified in drinkers

(>15g/day) of all ethnicities other than Afro Americans, as well as underweight individuals and those with a lower fibre and folate intake confirming the findings of the WCRF.

before symptoms. With regard to nutrition and cancer it is becoming clearer that it is the whole set of nutritional exposures over our lifetime that determines the individualâ&#x20AC;&#x2122;s susceptibility to exogenous and endogenous carcinogenic exposures. The protection of our body from these exposures depends on the oxidative metabolism and healthy cell regeneration but this process may be impoverished by poor nutrition and ageing. The WCRF have identified

modifiable lifestyle behaviours which impact on cancer risk but increasingly it is being recognised that each risk factor does not act in isolation and it is a pattern of diet and activity conforming to the WCRF recommendations that helps to reduce risk of several cancers and of total mortality.

to environmental and lifestyle risk factors impacts on cancer risk. This is attributable to a lack of funding for cancer prevention, only 2 to 9% of global cancer research funding is in cancer prevention, with treatments for established cancer being favoured for ease of conducting research, financial reasons and an emphasis on reaction rather than proaction. More research is needed into epidemiology and molecular biology to identify the mechanisms through which diet, exercise, and other lifestyle factors that are unambiguously associated

with cancer lead to the disease. Further research will hopefully discover additional preventable causes e.g. early-life exposures, allowing for the development of further guidance to reduce cancer mortality. In addition the authors argue for more behavioural and policy research into barriers to adoption of effective evidence-based interventions.

Conclusion: Individuals of all ethnicities are at greater risk of cancer if they consume alcohol and that risk increases according to the amount and frequency of drinking.

Conclusion: It is important to adhere to as many WCRF guidelines as possible to minimise the risk of developing cancer.

Conclusion: The authors envisage a 70% reduction in cancer mortality globally if the proposed research came to fruition, even without the development of any new therapies.